Tremfya is much, much harder to get than I imagined

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I took this photo of the sunset over the ocean on last month’s Alaska cruise. It reminds me of calmer waters and more joyful times as I persisted in getting my Tremfya prescription right over the past few weeks since.

The journey began in May simply enough: get Tremfya renewed for another year at a new specialty pharmacy. I have continued to use my previous dermatologist’s prescription this year, but with a new doctor I needed a new prescription at a differeent pharmacy starting this summer.

My dermatologist and I decided to request every 6-week dosing, which we both thought would be denied. But it was worth a try, right? No. Denial came swiftly and ended up costing me a lot of time waiting and on the phone.


My dermatologist and I decided to request every 6-week dosing, which we both thought would be denied. But it was worth a try, right? No.


For me simple is never that simple when it comes to getting the newer, more expensive (good) medications to treat severe psoriasis.

(Barely) Qualifying to Receive Tremfya Coverage

After the DENIAL for every 6-week dosing schedule for Tremfya, I was glad to see they approved every 8-week schedule. It’s what I expected anyhow since it makes financial sense for the insurance provider to not pay more than it has to, even though I’ve shown I need a higher frequency dosing.

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With that letter describing how 6-week dosing is not covered, WHA did explain the criteria for receiving coverage for Tremfya. I couldn’t believe how incredibly restrictive the criteria are, including failing two of the newer medications/biologics:

WHA [Western Health Advantage] covers Tremfya when all the following criteria is met:

[1] when prescribed for moderate to severe plaque psoriasis confirmed by a dermatologist (psoriasis affects 10% or more of the body; psoriasis involves hands, feet, and neck or genitalia).

AND

[2] prescribed by a dermatologist

AND

[3] the patient has tried and failed topical therapy (e.g., Dovonex, Tazorac, or other topical steroids),

AND

[4] documented failure or clinically significant adverse effects to one of the following therapies alone or in combination, unless contraindicated: methotrexate or (if methotrexate in contraindicated) cyclosporine, acitretin, or a trial with PUVA or UVB for at least 3 months unless intolerant,

AND

[5] documented failure or significant adverse effects to at least two of the following: Humira, Otezla, Stelara, or Cosentyx.

Initial approvals are considered for 3 months to assess patient’s response and renewals for one year.


I couldn’t believe how incredibly restrictive the criteria are to receive Tremfya, including failing two of the newer medications/biologics.


This is how I imagine the insurance provider reviewer went about his job when fe came to my case:

Let’s see if we can deny him coverage somehow like many of the others. Hmmm. Psoriasis over 10% coverage on those difficult, embarrassing spots–check. Topical therapy—check, check. Failing MTX, cyclosporine (due to side effects), acitretin, PUVA and UVB—oh yes, all of the above.

What about the other expensive stuff? Humira, Otezla (even though we didn’t approve it, he tried and failed it!), Stelara, and, wait, where’s Enbrel? Oh, he hasn’t tried Cosentyx—yet. Sigh, I guess we need to approve it, but only for every 8 weeks.


Follow my Tremfya journey!

Tremfya (Guselkumab) Week One  

3 Weeks with Tremfya: The Waiting Game

8 Weeks with Tremfya: It’s Working!

12 Weeks with Tremfya: The Third Injection

16 Weeks with Tremfya: The Verdict?

20 Weeks with Tremfya: Read the Instructions! (4th Injection)

24 Weeks with Tremfya: A Pattern Emerges

28 Weeks with Tremfya: Still Working? (Injection #5)

38 Weeks with Tremfya: The Q&A Edition


The Mess of Ordering and Paying for Tremfya

Approval for another year of Tremfya took some time to put it mildly. The first try to fill the prescription ran into a problem with the prescription itself. The original one from my dermatologist expired in late May due to lack of a prior authorization approval. Now we had the prior authorization I needed a new prescription for the pharmacy to fill it.

After another message to my dermatologist, the new prescription finally went through to the Accredo specialty pharmacy. But before contacting me or notifying me, I saw a $500 copay charge go on my credit card. I immediately called to get that straightened out. The clerk told me the auto pay kicked in and that the copay card from Janssen had not been submitted.

More calls and messages ensued—first to the old specialty pharmacy. I’m very grateful to Johnny at UC Davis Health pharmacy for calling Accredo directly with my Tremfya copay card information. After Johnny called I made another call to Accredo to take off the autopay and confirm the copay card information was in effect.

A week later, after checking Accredo’s website daily with no update, I called them yet again. Everything was in order, the clerk said, but they hadn’t initiated the Tremfya delivery yet. What are you waiting for?!? They thanked me for calling so they could expedite the shipment.

On Tuesday Tremfya finally arrived at my doorstep via overnight delivery shipped from Phoenix. That evening, I noticed the $500 charge on my credit card clear my account.


On Tuesday Tremfya finally arrived at my doorstep via overnight delivery shipped from Phoenix. That evening, I noticed the $500 charge on my credit card clear my account.


Guess what? I called them yesterday to request a refund. Sigh, there’s another twenty minutes of my life spent on the phone trying to help others get it right. Turns out it will take 3-5 business days for that refund to go back on my credit card. Apparently, they could not reverse the autopay once it initiated payment. Autopay happens to bypass the copay card system–even if you call them twice to make sure it doesn’t.

Oh, and by the way, if you don’t see the refund in a week, they told me, call back.

 

I now feel justified in starting the annual renewal process with the new specialty pharmacy Accredo two months before I needed another injection. I don’t like the fact I needed to coordinate among myself, the dermatologist’s office, the health insurance provider (Western Health Advantage), and two specialty pharmacies. But that’s what needed to happen to get that syringe of Tremfya to my house on time for my next injection.

I keep learning and teaching the lesson of advocating for yourself. It’s not hard when you know you need a medication to keep functioning, but it sure is tiring and frustrating to keep at it until things are reasonably resolved. Hopefully now I won’t have any more complications—as long as they refund my $500 minus a much smaller copay!

Stay tuned for a one year update on Tremfya in a couple weeks after I take my next injection.